Provider Demographics
NPI:1255404315
Name:PAK OPTICAL OF WATERTOWN INC
Entity type:Organization
Organization Name:PAK OPTICAL OF WATERTOWN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OPTICIAN NYS LICENSE
Authorized Official - Phone:315-782-8860
Mailing Address - Street 1:111 COURT STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2534
Mailing Address - Country:US
Mailing Address - Phone:315-782-8860
Mailing Address - Fax:315-782-8863
Practice Address - Street 1:111 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1116
Practice Address - Country:US
Practice Address - Phone:315-393-7754
Practice Address - Fax:315-782-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC4952156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01687530Medicaid